Medication

Care

Here you maintain each client’s medication plan and document every administration – who gave, refused or missed which medication and when.

What you do here

Use „New medication“ to capture name, dosage, unit, frequency (e.g. Morning), route and the period for a client. In the detail view you see the history of all administrations and document each new one via „Document administration“ with an outcome (Given, Refused, Missed) and a note. Mark paused or stopped medications via the status.

Tips

The „Active“ tab shows only ongoing medications – ideal for rounds. Carers may document administrations even without being able to edit the plan. Use the frequency „As needed“ for PRN medication that is not given at fixed times.

Legal requirements

Controlled drugs (BtM) are handled separately under BtMG/BtMVV: flag the medication via „Controlled drug (BtM)“ and, if applicable, state the BtMVV schedule (I/II/III). Every medication requires a medical prescription (SGB V §31, SGB XI) – record the prescriber, prescription date and prescription reference. Administering controlled drugs follows the four-eyes principle (dual signature, BtMVV): a second carer confirms the administration via „Verified by“/„Verified at“. Care documentation must be audit-proof and – depending on the applicable rules – is typically retained for 10 years („Retain until“). NOTE: per-carer read access and the technical enforcement of the dual signature follow separately; only the fields are provided at this stage.

Data protection

Medication and administration data are health data and thus a special category of personal data under Art. 9 GDPR. They require heightened protection: restrict access strictly to what is necessary for care, document every administration traceably, and retain data only within the statutory retention periods. Do not record information beyond the care purpose.

What you can do here

✓Medication
✓Medication
✓New medication
✓Edit
✓Delete
✓Set status
✓Document administration

Build it in the configurator →

Medication

Live preview — real view with sample data